Program Applications and Forms

Medications

Eligibility Requirements

Must have no prescription insurance, be ineligible for any state and federal programs

Those with Part D Eligible?

Considered on exception basis

Income

At or below 500% of FPL for oncology products and at or below 250% of FPL for all other products

Diagnosis/Medical Criteria

Medically appropriate condition/diagnosis

US Residency Required?

Yes

Application

Obtaining

Call or download

Receiving

Faxed, mailed or downloaded from website

Returning

Fax or mail

Doctor's Action

Complete section and sign

Applicant's Action

Complete section, sign, attach a copy of proof of income

Decision Communicated

Patient and Doctor are notified

Decision Timeframe

2-4 business days

Medication

Amount/Supply

Varies

Sent To

Doctor's office

Delivery Time

Within 2-4 business days

Refill Process

Reorder form needs to be submitted

Limit

None

Re-application

New application, new documentation yearly

Additional Information

Negative decision may be appealed. Insurance benefits, claims assistance and/or other reimbursement help is offered. Exceptions to guidelines considered.

Patients who do not file taxes must either request a 4506-T form from the IRS, submit proof of benefits received (such as Social Security) Earning Statement, or submit W2's of the person who is supporting them financially.

Healthcare provider must contact the Program for REORDER FORMS.

*On most medications, excluding Lovenox, patients with Medicare Part D may be considered if they are not eligible for Low Income Subsidy, and they have spent at least 5% of annual household income on out-of-pocket costs for medications.

Updated December 27, 2017

Last Modified 10/17/2017 05:27:19

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